Pay for primary care is central issue, part 2 of a 3-part series

When the American College of Physicians issued a white paper outlining its support for the establishment of a single-payer or public option healthcare system, there was no hint that 2020 would unfold as the most perilous year for U.S. medicine in more than 100 years. Nonetheless, the case made by the ACP remains a compelling one—so much so that BreakingMED is offering its users as chance for a second look. This second part of a three-part deep dive into the ACP proposals was originally published Jan. 21, 2020.

On Monday, Jan. 20, the American College of Physicians called on the United States to transition to either a single payer or a public choice option to move the nation to universal healthcare.

In its second position paper, part of an 85-page supplement published in the Annals of Internal Medicine, the physicians’ group took a deep dive into “Health Care Delivery and Payment System Reforms.” One of the cornerstones of this paper was recognizing the value of primary care and internal medicine specialists.

“In 2017, one quarter of U.S. health care payments were tied to some type of pay-for-performance or other quality-based program based on the existing [fee for service] FFS system, whereas another one third were tied to [value-based payment] VBP reform models,” Shari M. Erickson, MPH, with the American College of Physicians, Washington DC, and colleagues wrote. “Those numbers are rising, but less than 4% of payments were based on a population-based payment not built on the FFS architecture. As our nation’s health care payment and delivery systems move further along the value-based trajectory, it is important to consider where current value-based models are going awry.”

Erikson and colleagues go on to write: “The FFS system undervalues the skills of internal medicine specialists and the complex cognitive services they provide relative to procedures. Without fixing the foundation on which these value-based initiatives are built, our country will continue to see shortages in a physician workforce prepared to meet the demands of an aging and complex patient population and the demands of a delivery and payment system that depends on primary care physicians to manage care.”

Key issues include:

Recognizing and supporting the role of primary care and internal medicine specialists

“The ACP believes that it is essential that payment policies recognize the value of primary care and that payment is sufficient to reverse the primary care physician shortage,” Erikson and colleagues wrote, noting that primary care access “has consistently been associated with higher quality of care, lower mortality rates, higher patient satisfaction, and lower total system costs.”

To this end, the paper authors noted the following statistics:

  • Increasing 1 primary care physician per 10,000 people in 1 state was associated with a rise in that state’s quality rank by more than 10 places and a reduction in overall spending by $684 per Medicare beneficiary.
  • Adding 1 primary care physician per 10,000 people in the United States resulted in a 6% decrease in all-cause mortality, which amounts to approximately 114,520 fewer people dying in the United States each year… this amount would reduce inpatient admissions by 5.5%, outpatient visits by 5%, and emergency department visits by 10.9%.
  • Hospitalization rates and expenditures for ambulatory care–sensitive conditions also tend to be higher in areas with limited access to primary care.
  • With an estimated 5 million admissions to U.S. hospitals, costing approximately $26.5 billion, which are probably preventable with high-quality primary and preventive care treatment, substantial savings are possible with a robust primary care workforce.

Erikson and colleagues pointed to the consistent undervalued status of internal medicine specialists and other primary care specialists, which in turn has led to physician burnout and fewer medical students choosing primary care careers.

“General internal medicine physicians play a critical role in primary care,” they wrote. “They are responsible for the prevention, diagnosis, management, and treatment of a wide array of conditions and assume principal responsibility for coordinating and managing patients’ overall care, particularly for those with multiple complex chronic conditions. This role should be supported with adequate payment. The typical primary care physician coordinates with 229 other physicians in 117 different practices in the course of 1 year.”

They noted that 6 in 10 adults have at least one chronic disease, and 4 in 10 have 2 or more, accounting for $3.3 trillion in annual health costs.

Patient and family centered care — moving from the triple aim to a quadruple aim

“Effectively partnering with patients and their families is critical to achieving the ’quadruple aim’ of health care: enhancing the patient experience, improving health outcomes, lowering costs, and improving physician satisfaction,” they wrote. Erikson and colleagues noted the importance of engaging patients in their care and understanding their goals, socioeconomic status, personal values, and lifestyle, as well as their personal health goals, in order to achieve better clinical outcomes overall.

Transparency and informed shared decision making

“To attain maximum system efficiency and patient satisfaction, major treatment decisions should involve shared decision making between the physician and patient based on the clinical evidence, patient preferences, and cost,” Erikson and colleagues wrote. In order to inform these decisions, patients need information on the “services, physicians, care teams, and treatments that are right for them, in a way that a wide range of patients with varying cultural and educational backgrounds can understand” … this includes pricing information.

Moving to value-based care

In order to reform delivery and payment systems, “[p]hysicians and their clinical care teams should have a variety of voluntary VBP models to choose from to help them deliver high-value care that meets the needs of a diverse patient population,” Erikson and colleagues wrote. The paper authors noted that models should include varying levels of risk and reward, as well as “appeal to a wide range of practices with differing abilities to take on financial risk.”

Capitation also needs to be considered when looking at delivery and payment systems — such as the hybrid capitated payment approach of patient-centered medical homes.

“Payment approaches vary, but typically include a prospective per patient, per month fee; ongoing FFS payments; and retrospective payment adjustments based on performance,” they wrote.

Direct primary care (DPC) is another capitated model where the role of the third-party payer is eliminated and the patient contracts directly with the practice.

“The strength of the DPC model lies in its ability to leverage price transparency, improve timely access, and make participating clinicians fully accountable for cost,” the paper authors wrote. However, they noted the model can limit patient access in terms of “affordability to patients and downsizing patient panels.”

Removing administrative complexity and improving quality metrics

The paper goes on to point out that administrative complexity and burden also needs to be addressed in a move to universal health care, as well as improving quality metrics, on which VBP are based. Right now, the focus is on measuring performance, and it is not clear if the metrics actually capture quality of care.

“The American College of Physicians recommends that value-based payment programs move away from ’check the box’ performance requirements toward a limited set of patient-centered, actionable, appropriately attributed, and evidence-based measures for public reporting and payment purposes, while also supporting the use of additional clinically meaningful measures for internal quality improvement,” Erickson and colleagues wrote.

Improve and redesign health IT

And lastly, in order to further enhance the patient-physician relationship and improve payment and delivery of care, health IT systems need to be reformed to “prioritize the needs of patients and frontline physicians and their clinical care teams, strive to remove non-value-added interactions, and support value-based payment reform initiatives,” they wrote.

On Tuesday, Jan. 21, a full-page ad signed by nearly 2,400 physicians as of Jan. 17 appeared in the New York Times supporting the ACP’s call for universal health care. The ad was sponsored by Physicians for a National Health Program.

Candace Hoffmann, Managing Editor, BreakingMED™

Erikson disclosed no relevant relationships.

Cat ID: 925

Topic ID: 915,925,791,730,192,150,462,463,590,60,61,925